W S. is a 36-year-old African American male who presents to the clinic for follow-up psychiatric evaluation and medication management with the diagnosis of unspecified depressive disorder and Alcohol/Ecstasy use. Chief complaints: “I’m here for a follow-up.” The patient presents restless, with euthymic mood and affects. He presents with fair insight and judgment. There was no display of psychosis. He reports no significant issues with sleep, appetite, or energy levels. No display of emotional or perpetual disturbance. The thought process is clear and coherent, and the content does not reveal delusion, paranoia, or suicidal ideations. He reports, “my anxiety is a bit worse; I just lost my dad, and I am down a lot lately.” He stated that his current psychotropic has been working for him, but he needs some therapy/counseling due to the recent death in the family. The patient reports having the urge to drink again since this past event in the family. The patient is single but in a relationship. He lives with a friend and renting. Denies any past inpatient or outpatient hospitalization. Denies any past history of family psychiatric illnesses or substance abuse.
Assessment diagnosis: Unspecified depressive disorder, substance abuse disorder, Alcohol abuse, anxiety disorder
Medication: Remeron 30mg PO QHS, Celexa 20 mg PO Q AM, Zoloft 25 mg PO Q daily.
Treatment Plan: The plan is to continue with the current medications and referral for therapy.
The next appointment is to be scheduled in 1 month.
Classroom Productions Links to an external site.. (Producer). (2016). Impulse and conduct disorders [Video]. Walden University.
Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar Links to an external site.[Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE